Summary Report for FSPSAs Initiated During the Report Period Center: 52
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 631 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 1.477778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.477778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 4 5 5.000000 $257.0500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SCREEN-T1023 SCREENING 36 36 36.300000 $1815.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $359.8700 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $154.2300 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 11.285714 $597.3500 $52.9300
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Subtotal (Total Children Is Unduplicated) 54 62 72.585714 $3697.6000 $50.9400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 8.600000 $430.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 102 125 291.999999 $14600.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 78 228.790476 $11439.5200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 36 89.833336 $4491.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 58 133.266665 $6663.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 8.800000 $220.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.133333 $28.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 151 768.357148 $38417.8200 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 23 89.566666 $6445.2100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 7.800000 $561.2900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 9 10 73.361902 $4225.6500 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 17 18 64.910715 $4670.9700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 21.504762 $1237.8100 $57.5600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.825000 $131.3300 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 53 257.319048 $18516.6600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.000000 $287.8400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 1.033333 $14.4200 $13.9600
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Subtotal (Total Children Is Unduplicated) 219 567 2053.102383 $112431.8500 $54.7600
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Total 631 2127.165875 $116129.4600 $54.5900
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Number of Children (Unduplicated) With at Least One Authorization 247